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they had ever taken and to provide the same details about these
events.
In the 3 NYSPI studies that used the CUAMI, interviews
were conducted with depressed patients while medication-free
before ECT, medication-free within a few days of terminating
the randomized ECT course, and at 2-month follow-up. In the
third study, the CUAMI was also administered at a 6-month
follow-up to examine further the persistence of decits.
The baseline CUAMI interview in depressed patients typically took between 1 and 3.5 hours. In the rst NYSPI study to
use the CUAMI,19,23 family members or close friends were also
administered the interview (from the point of view of the patient) to identify a subset of items that could be corroborated
for accuracy. This was done to guard against the possibility that
depressed patients may be especially likely to be inaccurate in
their recall of prior events and that inconsistency in responses
over time could be due to more accurate recall at later time
points. In this rst study, of the 75 patients with baseline
CUAMI data, a family member or close friend corroboration interview was available in 52 instances.
In this rst study, a normal control sample was also
interviewed on one occasion. This group, negative for lifetime
psychiatric disorder, was matched to the patient sample in the
distributions of age, sex, education, socioeconomic status, and
verbal IQ.26 The purpose of the normal control group was to estimate the extent to which productivity of memory at baseline was reduced in the patient group, thereby perhaps biasing
post-ECT RA measures.19 In the second and third studies to
use the CUAMI, a similarly selected normal control group
was tested on 2 occasions, averaging approximately 4 weeks
apart, corresponding to the mean interval between pre-ECT
and immediate post-ECT testing in patients. This allowed for
the determination of the extent to which CUAMI amnesia scores
in patients exceeded the rates of normal forgetting or inconsistency in memory reports over time.
In all studies, CUAMI interviews after baseline (eg, immediately after ECT) only inquired about items that had a denite
reply at baseline. Inquiries were not made about items that
at baseline participants said they did not know or could not remember the answer or that the query did not apply to them. In
this way, a subset of items was identied for each participant
such that the participant had evidence of a denite memory at
baseline. Thus, the CUAMI RA scores concerned only material
that was previously known and did not attempt to quantify the
extent that participants would provide responses at follow-up
when they could not do so at baseline.
The CUAMI elicits multiple details about 43 discrete
events (eg, best trip = a trip to Italy). If at follow-up testing
the participant did not spontaneously recall a specic event or
were inconsistent in the event reported (eg, now a trip to
California instead of Italy), they were reminded about the original description. When participants explicitly recognized the
original event, subsequent queries about details pertained to
the event described at baseline. When participants did not recognize the original event, there was no questioning about the
details of this event.
The primary outcome measures in all 3 NYSPI studies using the CUAMI focused on the 185 items requiring a descriptive
response (43 discrete events and 142 event details). The key
measures of RA were the percentage of responses at follow-up
that were consistent with responses at baseline and the number
of pure memory failures. Pure memory failures were instances
in which the participant could no longer provide any information about a query that was previously denitely answered. Consistency (or its inverse, inconsistency) provides a more liberal
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measure as it includes, as indexing RA, both pure memory failures and changes in the description of events and event details.
The rst study using the CUAMI at NYSPI randomized
patients to RUL and BL electrode placements.19,23 Patients
were also randomized to low (just above seizure threshold
[ST]) and moderate (2.5 ST) dosage conditions. Patients
who did not meet response criteria received a second crossover
course of BL ECT at 2.5 ST, regardless of their original randomized treatment assignment.
The ndings in this study, reported in detail by McElhiney
et al,19 demonstrated that immediately after the randomized
ECT course, patients treated with BL ECT were more inconsistent in their responses and had substantially more pure memory
failures than patients randomized to RUL ECT. This advantage
for RUL ECT was maintained across multiple consistency
measures, including separate analyses for recent and remote
events and for affectively charged and neutral events. In contrast, there was no indication that electrical dosage condition affected RA scores.
At 2-month follow-up, patients who received a second
crossover course of BL ECT had inferior RA scores than those
who received only one course of ECT. Indeed, relative to the assessment immediately after the randomized ECT course, RA
scores deteriorated in the patients who had a crossover course
and improved somewhat in the patients who received only one
ECT course. Furthermore, there were also effects of initial electrode placement on the long-term RA measures. Patients randomized to BL ECT had inferior consistency scores at the
2-month reassessment than patients randomized to RUL ECT.
Thus, technical factors in the administration of ECT, specically electrode placement and receiving 2 course versus 1
course of ECT, but not electrical dosage, affected CUAMI RA
scores. There is the theoretical possibility that when a subgroup
demonstrates greater inconsistency over time in memory reports, increased rather than decreased accuracy in memory recall may be mediating this difference. There were 3 sets of
evidence that indicated that this was a very unlikely explanation
of the effects found with the CUAMI. Across multiple analyses,
the effects obtained with inconsistency scores were tracked by
those obtained with scores for pure memory failure, the dont
remember responses. It would be absurd to argue that the
higher rate of pure memory failure with BL or crossover ECT
reected an improvement in the accuracy of recall, as patients
in these groups were more commonly stating they did not remember the answer to a query that they previously provided
a denite response. Whereas the effects seen with the primary
consistency measure were tracked by the measure of pure memory failure, the effect sizes tended to be greater with the consistency measure. This led to its preferential use in subsequent
studies.
A second reason for doubting that improved accuracy over
time substantially affected the CUAMI ndings concerned the
corroboration provided by family members and friends. In the
patient group as a whole, there was greater consistency over
time for corroborated versus noncorroborated items, demonstrating perhaps a difference in the memorability or resistance
to RA of events and event details known by others. Regardless,
when restricting analyses to only corroborated baseline reports,
the pattern of ndings was unaltered. For example, the effects
of treatment parameters (electrode placement and number of
ECT courses) were maintained. Indeed, in light of the presence
of marked redundancy in the effects observed with all items
and only corroborated items, the use of family/friend corroboration was deemed unnecessary and dropped in future studies
using the CUAMI.
2014 Lippincott Williams & Wilkins
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Commentary
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Commentary
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indices, and patient self-report. However, it is likely that the instrument has many extraneous items, as the principal dependent
measures derived only from the subset of items that required a
descriptive response, whereas other types of items were ignored. Furthermore, the instrument includes sampling of recent
and remote events as well as emotionally charged (positive and
negative) and neutral events. These items were included to examine the intrinsic characteristics of the RA but were likely
overkill in providing a measure of the overall severity of
RA for autobiographical information. Thus, the CUAMI-SF
was created to address the need for a much briefer instrument
for use in multisite studies and in routine clinical practice.18
The items on the CUAMI-SF concern 6 events: last major
overnight trip, last New Years Eve, last birthday, most recent
employment, most recent medical illness, and details about an
important family member or friend. For each of these 6 categories, 5 queries are made to probe memory of specic details,
producing a total of 30 items. The event and detail queries were
selected from the much larger set in the CUAMI based on 2 criteria. First, we identied events and details that produced high
and equivalent rates of response at baseline in the depressed
patients and matched normal control sample administered the
CUAMI at NYSPI. Second, among potential items, we selected
those that maximized the difference between RUL and BL ECT
in the randomized NYSPI studies. We presumed these selection
criteria would enhance sensitivity of the instrument to RA for
autobiographical information.
The CUAMI-SF is administered and scored in a manner
similar to the CUAMI. In particular, at follow-up testing, inquiries are made only about items that had a denite response at
baseline. Thus, the collection of memories subject to assessment is individualized for each participant, and memory consistency is tested only for items that at baseline provoke an
identiable memory. Scoring at follow-up allows partial credit
when reports partially correspond to baseline responses. The
baseline response is automatically scored 2 if a denite and
identiable memory is elicited and otherwise scored zero,
corresponding to reports that participants do not know or remember the answer to the question or that the query does not
apply to them. Only queries scored as 2 at baseline provide
the material tested at follow-up. Follow-up responses are scored
as zero (no response or fully inconsistent), 1 (partially consistent), or 2 (fully consistent). The RA score used in research with
the CUAMI-SF is the total score at a follow-up relative to the
score at baseline. This reects the percent consistency in responses and is maximally 100%, with increasing inconsistency
resulting in lower scores. The CUAMI-SF usually takes 15 to
20 minutes to administer.
The CUAMI-SF was rst applied in the multisite study examining efcacy and cognitive effects in community ECT settings, often referred to as the Services study.7
This prospective observational study was conducted with an
intent-to-treat sample of 347 depressed patients who received
ECT at 7 different hospitals in the New York City metropolitan
area.7,44 The CUAMI-SF, a primary outcome measure in this
study, was administered as part of a larger neuropsychological
battery before ECT, within a few days of ECT termination, and
at 6-month follow-up. Normal controls, never psychiatrically ill
and matched to the patient sample in the distributions of age,
sex, and education were tested at the same intervals as patients.
CUAMI-SF consistency scores in patients were adjusted for the
extent of inconsistency found in the normal comparison sample
over time. This allowed determination of the extent to which
CUAMI-SF inconsistency scores at follow-up exceeded the normal rate of inconsistency in autobiographical recall.
2014 Lippincott Williams & Wilkins
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Commentary
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domain shows the most persistent and severe decits after ECT.
At the same time, it is also apparent that we should not throw
out the baby with the bath water. The CUAMI and CUAMISF have taught us a great deal about this potential adverse effect
of ECT. To discard this knowledge, would, in fact, be throwing
out the baby owing to objections that are either erroneous or
narrowly technical. Indeed, as innovations in ECT, such as the
use of ultrabrief stimulation, markedly reduce the severity and
persistence of this adverse effect, it will be even more important
to develop sensitive instruments to reveal any residual decits
and/or to substantiate the claim that risk of this adverse effect
has been eliminated.
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Commentary
19. McElhiney MC, Moody BJ, Steif BL, et al. Autobiographical memory
and mood: effects of electroconvulsive therapy. Neuropsychology.
1995;9:501517.
20. Weiner RD, Rogers HJ, Davidson JR, et al. Effects of stimulus parameters
on cognitive side effects. Ann N Y Acad Sci. 1986;462:315325.
21. Semkovska M, McLoughlin DM. Measuring retrograde
autobiographical amnesia following electroconvulsive therapy:
historical perspective and current issues. J ECT. 2013;29:127133.
47. Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal and
right unilateral electrode placement in ECT: randomised trial.
Br J Psychiatry. 2010;196:226234.
25. Sackeim HA, Prudic J, Nobler MS, et al. Effects of pulse width
and electrode placement on the efcacy and cognitive effects of
electroconvulsive therapy. Brain Stimul. 2008;1:7183.
26. Sackeim HA, Freeman J, McElhiney M, et al. Effects of major
depression on estimates of intelligence. J Clin Exp Neuropsychol.
1992;14:268288.
27. Frith C, Stevens M, Johnstone E, et al. A comparison of some retrograde
and anterograde effects of electroconvulsive shock in patients with
severe depression. Br J Psychol. 1987;78:5363.
28. Weeks D, Freeman C, Kendell R. ECT: III: enduring cognitive decits?
Br J Psychiatry. 1980;137:2637.
29. Janis IL. Psychologic effects of electric convulsive treatments. (III Changes
in affective disturbances). J Nerv Ment Dis. 1950;111:469489.
31. Blaney PH. Affect and memory: a review. Psychol Bull. 1986;99:229246.
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